Monday, June 20, 2011

New rules regarding vaccine exemptions

There are several new laws in various states regarding vaccine exemptions recently.

You can see the new and old versions of the vaccine exemption forms for one state here.

Previously, a medical provider was only required to sign the form for medical exemptions. Now, as of July 22, 2011, a medical provider has to sign the form for all exemptions except for one very narrow and strictly-defined type of religious exemption.

There is a limited list of approved health care providers, and all of them routinely charge for visits.

Some clinics are requiring separate appointments for each child to get the forms signed even if they have previously given the parents information about the benefits and risks of vaccines. So there may be a significant cost in money and time off work, etc. to fulfill this requirement.

The reality is that for many people this law is going to result in doctor appointments that otherwise wouldn’t have been needed in order to get their forms signed. Some families will not be able to afford this cost.

Even before this law was passed, health care providers were already required by law to give parents information about the benefits and risks of vaccines. The point of this law has nothing to do with making sure people are making an informed decision, and everything to do with simply making vaccine exemptions more difficult.

My child was not due for any doctor appointment this year (I actually called to make an appointment, and they told me she wasn’t due for her next well-child check until next year). But our pediatrician’s office said that they cannot sign the form without a well-child visit for that child in the current year.

So we had to make an otherwise-unnecessary appointment specifically to get the signature on the exemption form. We had already discussed it extensively with the doctor and received plenty of information, and agreed to hold off on one of the newly-required vaccines until the child is a bit older, although all the other vaccines are current.

Even with insurance, it’s costing me half a day and a copay just to get a signature saying that the doctor did what he was required to do.

Multiply that by the number of children, and it can become quite costly in missed work and/or school as well as financially.

Considering that medical providers were already required by law to discuss the benefits and risks of vaccines with parents, this seems unreasonable to me.

What do you think?


Douglas said...

The new form is not something that I could sign without marking it up for clarification. WA state has radicalized the allowable positions, contrary to what most people with religious objections believe. It reminds me of what the supreme court did in saying that only people who objected to all war could get exemption as a conscientious objector, effectively doing away with just war theory for conscientious objectors.

Kevin said...

I agree, Doug, but how would you mark up the form? Scratch out the provider requirement? :) AFAIK, it's not like a contract since it just reflects a legal mandate. In any case, schools could just reject your form, right?

But in the case of a personal religious exemption, requiring a doctor's signature may not even be constitutional since they would be acting as agents of the state and those who refuse to give care or provide such an exemption would be imposing a religious test.

The encroachment of government upon our liberties upsets me. Who advocated this? Doctors, I'd imagine. Pharma might also benefit. What pressing need does this serve? None.

purple_kangaroo said...

Doug, there are two boxes on the new form to check for religious objection. One just says "religious exemption" and requires a signature from a medical provider, just like the persona/philosophical and religious exemptions.

This specific form is not required by law, but a signature from a medical provider is required by law for anyone wanting an exemption from vaccines--basically an affadavit from a doctor that they have given you information on the benefits and risks of vaccination (something they were, again, already required to do by law).

The ONLY way to get out of the requirement for a signature from a doctor is to sign the affadavit testifying that you are "a member of a church or religious body whose beliefs or teachings do not allow for medical treatment from a health care practitioner" and provide the name of the church or religious body.

In other words, you are not allowed to get out of getting a signature from a doctor for any reason, religious or otherwise, unless you belong to something like a Christian Scientist church that doesn't allow anyone to see any doctor for any reason.

If you don't get this signature from a doctor, your child can be excluded from school or other activities that require vaccines.

Douglas said...


Thanks for the clarification. I thought one needed to *both* sign it oneself and get a doctor's signature.

I'm a bit surprised at the limited list of approved health care providers. This seems particularly invasive and big brotherish. Such a requirement seems designed to force one to go to go to a very pro-vaccine doctor that the government likes.

Does one need to turn in a new form every year, or will last year's form suffice?

Douglas said...

Kevin, As PK pointed out, I misunderstood the form. You are correct that the school would likely have rejected a marked-up form, if it was required. I might have marked it up anyway, since only one or the other would be required and such markings wouldn't necessarily have voided it. I would have marked out "do not allow
for medical treatment from a health care practitioner" and written in "stands by my right to forego certain vaccinations manufactured in violation of certain peoples' human rights"

purple_kangaroo said...

Doug, you are supposed to both sign it yourself and have a medical provider sign it. The only people exempt from having a medical provider sign it are those who belong to a religion that forbids seeing a medical provider.

Yes, it is a very limited list of approved medical providers. None of which are generally free, eiher. :)

purple_kangaroo said...

Most parents, though, will sign "Box 3"--you only sign Box 2 if you fit into that specific type of church/religious organization that forbids seeing a doctor.

You only have to turn in an exemption form once per exemption needed, according to the FAQs. So one form would be good until the child reaches an age that new vaccines would be required, for example.

purple_kangaroo said...

Kevin, the doctor isn't signing to approve the religious exemption. They're only signing an affadavit that they gave the parent information on the benefits and risks of vaccination.

Kevin said...

PK, yes, but the exemption is not granted without the doctor's signature, making them the gatekeeper to some religious exemptions. As you said, the point of the law is simply to make non-medical vaccine exemptions more difficult, which may be unconstitutional if it results in de facto religious discrimination.

As Doug mentioned, they try to get around that by "radicalizing" religion in order to narrow First Amendment protections. i.e. They separate "personal or philosophical objection" from "religion" and restrict the latter to those religions that deny all medical treatment. This gives preferential treatment to those religions.

Private doctors might even lose their freedom to discriminate since they could be seen as state actors in this narrow case. Can doctors refuse patients who are not vaccinated because of their religion? Normally, yes, but if they must fulfill a state obligation, maybe not.

Also notable is that the Certificate of Immunization Status does not appear to include an affidavit that the doctor informed the patient of the benefits and risks of vaccinations. Ironically, AFAIK (maybe I'm wrong), federal law only requires informed consent before giving vaccinations, not when NOT giving vaccinations. This may not be actionable but it is revealing of their intent.

Washington might be able to just remove all non-medical exemptions but maybe there's also a case for the right to choose your own medical treatment except in serious public health emergencies.

But IANAL, these are just my ideas for how it might be challenged. It's a tricky piece of legislation. I'd be surprised if most legislators realized the subtle implications.

MarkC said...

This will probably get me into some serious hot water with the other commenters here (especially the one I'm most closely related to)... but I can see the logic behind this new form, and I don't think it is necessarily nefarious.

Without the doctor's affidavit on the form, one could simply say "I don't want to give my child vaccines" and sign it, and that was that. Maybe that's the way it should be. But, I will say that when I was signing my kids up, and I was behind schedule and worried about scheduling, and I saw that exemption form... I would have been quite willing to claim a "personal exemption" on the spot, whether I had given the issue any real thought or not, just to save the hassle of filling out the long complicated form.

The old form provided no barrier at all to a deadbeat parent who just didn't want to deal with the hassle of vaccinations, or of double-checking whether their child had had vaccinations. It would be extremely easy to just take the cop-out route, claim some nebulous "personal exemption", sign it, and never give the issue another thought.

Now, did anyone actually do that? I don't know. Was it a big problem that needed a legislative response? Maybe not. Did some of the legislators have other, more nefarious motives? Maybe.

But I can see a plausible reason to vote for this change that doesn't involve anything more than a sincere desire to make sure parents have really considered the issue with proper information before claiming a personal exemption.

It just adds a barrier to the easy cop-out of the personal exemption option.

Does that make it right? I don't know, and I don't plan to make any stand on that issue. (I have too much relationally at stake to do so!) I just thought I'd add a minor counter-point to the prevailing discussion.


Purple_Kangaroo said...

We saw the pediatrician today. It took him an extra 5 or 10 minutes just to fill out the vaccine exemption forms, sign them, and have me sign them. He said, "You already know how I feel about vaccines, we've talked about it plenty in the past, and I know you have reasonable concerns about giving your kids these vaccines." So he signed the forms without giving me any new or different information than he already has in the past.

He said they're getting swamped with appointments from people who need exemption forms signed. He said the medical professionals aren't any happier about the new law than I am. It is a colossal waste of doctor time and resources

Mark, the thing is that if you take your child to the doctor, at every single visit they talk to you about vaccines. Doctors were already required by law to do what this form is supposed to be verifying they do.

The only reason you personally might be able to sign an exemption form without having given it much thought, is that you're not usually the one who takes the kids to all their doctor appointments and checkups. It's impossible to go to the pediatrician's office without being forced to think about and explain to the doctor your reason for not wanting any given vaccine that you are refusing or delaying.

The point is, parents *already* have to discuss this decision with their child's doctor, be given information, and explain their decision. This law doesn't do anything except add red tape and a higher cost in time and money to what was already happening quite effectively without it.

Purple_Kangaroo said...

Kevin said, "As Doug mentioned, they try to get around that by "radicalizing" religion in order to narrow First Amendment protections. i.e. They separate "personal or philosophical objection" from "religion" and restrict the latter to those religions that deny all medical treatment. This gives preferential treatment to those religions."

The thing is, they are not restricting all religious objections to that narrow group. There is another box to check for just plain "religious exemption" which is not dependent on that.

With the exception of those who have membership in a religious body that doesn't allow seeing doctors, religious exemptions are treated exactly the same as medical or personal/philosophical exemptions.

Kevin said...


I heartily second PK's encouragement of your commenting. I took your "hot water" remarks as humorous -- who doesn't enjoy a little hot water every now and then, maybe with a little lemon and honey? :) As long as you're not drowning in it.

I think you're right about the legislator's reasoning and their good motives to encourage fastidious parentage. I probably implied nefariousness but it's not, and you described it well. PK's hassles and the impingement of liberties I lament are unintended side-effects (or acceptable losses?).

In fact, I am coming to the conclusion that a lot of the problems of government are due to good intentions and unintended side-effects. People just are not smart enough to predict the ramifications of their rules and there are so many of them nowadays.

I'm reminded of a C.S. Lewis quote: "Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience."

I'm sure I exaggerate on this issue, but all the little things add up to a systemic problem.

Kevin said...


Oy! You're right, I missed the middle Religious checkbox, so my radicalization argument doesn't work, but hopefully the rest does.

I still question why some religions have different requirements. Seeing a doctor is not the same as being treated by one. AFAIK, there is no religion that prohibits meeting a doctor in order to be given information on the benefits and risks of vaccinations and get a signature.

And if it is bad for the government to mandate a discussion on how someone's religious belief is wrong, it should be bad for all religions.

purple_kangaroo said...

I deleted my comment above and am rewriting a bit because I reread it later and realized it didn't come across well.

You do have an interesting point, though, Mark.

While I doubt the new requirements will have much if any impact on the actual vaccination rates, it may have an impact on the number of forms filed.

I can see a scenario as you describe where children are actually vaccinated, but it's a hassle to actually get the vaccination records or the parent isn't sure about it, so signs the exemption form simply because that's easier.

I'm still not convinced that it would make a significant difference in the actual vaccination rates, since that is already something parents have to consider and discuss with their child's doctor.

Making a decision about which vaccines to get when is a lot more complicated than just signing a form, and I highly doubt this form is going to impact the actual vaccine decision for many families. It seems to me that most people are very unlikely to make a decision about vaccinations based solely on how complicated and difficult the exemption form is. :)

But I will concede that it might cut down on the number of unnecessary exemption forms filed. I doubt that affects public health in a significant enough way to counterbalance the resources used in meeting the new requirements, though.

But depending on how vaccination rates are calculated, it's possible that a reduction in the number of exemption forms filed could be hailed as proof that more kids are being fully vaccinated even if the actual vaccination numbers haven't significantly changed.

That is a very interesting angle I hadn't considered.

BTW, I didn't say I thought it was nefarious. At the moment I do think it's unreasonable, unnecessary, and a waste of time and resources for what amounts to nothing more than red tape. I think it's more likely that legislators didn't use their heads very well on this one than that they had some nefarious intent when voting on this.

And, Mark, please do share your thoughts and opinions even if you feel like you're the only one bringing up a differing line of thought. We all want to hear them!

The goal of any healthy discussion is that, even if there is disagreement, all parties can have and express opinions/concerns and have those thoughts taken seriously and interacted with in a respectful manner.

Your opinions are valuable and important even if you disagree with others on the blog and elsewhere. :)

purple_kangaroo said...

Kevin: Yes, I am not aware of any religion that forbids having a conversation with a doctor, but it would probably be an unreasonable burden on a person who doesn't see a doctor for anything, ever, to find a doctor who is willing to make an appointment, establish a patient relationship and pay for an appointment just to get the form signed. I think it's an unreasonable burden anyway, but it's even more onerous for someone who doesn't actually have a doctor, KWIM?

Also my kids' doctor wouldn't sign the form without doing a well-child exam, so the signature requirement can actually result in a requirement of getting medical treatment to some extent.